This case demonstrates the severe electrolyte derangements that may present after a common therapy such as a bowel preparation for an outpatient procedure and the rare yet potential detrimental outcomes of those abnormalities. It also highlights the implications of long QT syndrome regarding pharmacology and treatment.
Trang 1Schaar et al BMC Anesthesiology (2021) 21:302
https://doi.org/10.1186/s12871-021-01457-9
CASE REPORT
Torsades de pointes in the PACU
after outpatient endoscopy: a case report
Andrew Schaar* , Mark Liu and Michael Patzkowski
Abstract
Background: This case demonstrates the severe electrolyte derangements that may present after a common
therapy such as a bowel preparation for an outpatient procedure and the rare yet potential detrimental outcomes of those abnormalities It also highlights the implications of long QT syndrome regarding pharmacology and treatment
Case presentation: We present a case of 48 year-old female with severe electrolyte derangements and long QT
syndrome (LQTS) leading to Torsades de Pointes (TdP), pulseless ventricular fibrillation, and unsynchronized defibrilla-tion in the post anesthesia care unit (PACU) after uneventful upper and lower endoscopy This led to an unanticipated intensive care unit admission for aggressive electrolyte repletion, cardiology consultation, and implantable cardio-verter defibrillator (ICD) placement
Conclusions: This is a rare presentation after an outpatient procedure that would have had a detrimental outcome if
not promptly diagnosed and treated appropriately Therefore, we aim to provide further insight into the diagnosis and treatment of severe hypokalemia and long QT syndrome resulting in Torsades de Pointes and ventricular fibrillation
Keywords: Hypokalemia, Torsades de pointes, Acquired long QT syndrome, Congenital long QT syndrome,
Magnesium
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Background
Profound hypokalemia and long QT syndrome are rare
yet potentially life threatening abnormalities They
become even more significant when discovered
postop-eratively in a patient after a common outpatient
proce-dure such as an endoscopy Severe hypokalemia requires
a high index of suspicion for diagnosis and prompt
reple-tion to avoid further sequelae whereas long QT syndrome
may be congenital or acquired and may lead to sudden
cardiac death Written HIPAA consent has been obtained
from the patient and is available for review
Case presentation
Patient information
A 48 year-old female with diarrhea predominant irritable bowel syndrome and gastroesophageal reflux disease is scheduled for esophagogastroduodenoscopy and colo-noscopy under monitored anesthesia care Her other past medical history is significant for hypertension, depres-sion, anxiety, and a history of “paroxysmal supraven-tricular tachycardia (PSVT)” Regarding the diagnosis of PSVT, she described self-resolving syncopal episodes in her early adult life She stated she was currently being evaluated by a cardiologist with the suspected diagno-sis of PSVT yet no diagnostic tests had been performed prior to her scheduled procedure Pertinent medications include fluoxetine, buproprion, alprazolam, diltiazem, amlodipine, omeprazole, and ondansetron Social and family history were non-contributory She completed
a bowel preparation the day prior to presentation as
Open Access
*Correspondence: schaar2121@gmail.com
Brooke Army Medical Center – Fort Sam Houston, Anesthesiology
Department, 3351 Roger Brooke Drive, San Antonio, TX 78234, USA
Trang 2instructed along with minimal oral intake in the
preced-ing days due to her persistent nausea
Clinical findings
The anesthesia team was contacted by the patient’s nurse
in the post anesthesia care unit (PACU) for persistent
postoperative nausea, a frequent issue encountered in
the PACU The patient’s physical exam was unremarkable
with normal vital signs Electrocardiogram (EKG) on the
bedside monitor appeared normal The patient appeared
mildly uncomfortable stating nausea slightly worse than
her recent baseline
Timeline
The patient had an uneventful intraoperative course
under monitored anesthesia care with 2 mg (mg) of
mida-zolam given preoperatively and propofol titrated
intra-operatively to desired sedation level Postintra-operatively, she
was given intravenous (IV) ondansetron 4 mg and IV
pro-methazine 12.5 mg for persistent nausea as part of PACU
orders placed by the intraoperative anesthesia provider
The PACU anesthesia provider along with
gastroenterol-ogy were informed after nausea persisted beyond these
measures A scopolamine patch was ordered by her
sur-gical team as the patient was scheduled to be discharged
home and a scopolamine patch would potentially provide
prolonged antiemetic benefits Her nausea persisted with
now heightened anxiety Twenty milligrams of propofol
was given under full monitors with no effect noted Her
anxiety and restlessness increased for which her home oral alprazolam 0.5 mg was given
Approximately 60 minutes later, the patient’s bedside nurse alerted the PACU anesthesia team that the patient appeared to have a 10 second run of presumed supraven-tricular tachycardia for which she had a history of A stat EKG was ordered yet prior to being completed, the patient went unconscious and into pulseless ventricular fibrillation Unsynchronized defibrillation at 200 joules was performed followed by advanced cardiovascular life support Approximately 5 chest compressions were delivered before the patient was noted to be awake and moving spontaneously No medications were given dur-ing ACLS Return of spontaneous circulation obtained after approximately 30 s from the time she was noted to
be unconscious and the patient was now awake and fol-lowing commands
Diagnostic assessment
Stat EKG revealed inverted T waves, prominent U waves,
The rhythm strip from her earlier episode of presumed
consist-ent with polymorphic vconsist-entricular tachycardia (Torsades
de Pointes) Two grams of IV magnesium was initiated Laboratory evaluation revealed a potassium level of 2.4 mmol/L (critically low; Normal 3.5–4.5), phosphorus
of 1.0 mg/dL (low; Normal 0.97–1.45), ionized calcium 1.04 mmol/L (low; Normal 1.2–1.32), magnesium of
Fig 1 Post cardiac arrest EKG demonstrating inverted T waves, U waves, and QTc >600msec
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Schaar et al BMC Anesthesiology (2021) 21:302
2.3 mg/dL (normal 1.6–2.4), glucose 144 mg/dL (normal
fasting level 60–100) Chest radiograph obtained and was
normal The diagnoses of severe hypokalemia,
hypophos-phatemia, hypocalcemia, and suspected acquired long
QT syndrome were made The prognosis of those
condi-tions is favorable with electrolyte repletion and avoidance
of QT prolonging medications
Therapeutic intervention
After the diagnosis of Torsades de Pointes, 2 g of IV
mag-nesium was initiated and infused over 15 min Aggressive
potassium and phosphorus repletion was initiated with
both IV and oral replacement as the patient was awake,
fully oriented, and following commands The
medi-cal intensive care unit was contacted and admitted the
patient for continued electrolyte repletion and further
workup
Follow‑up and outcomes
During her hospital stay, the patient continued to have
long QT syndrome and experienced two additional
pulse-less ventricular fibrillation, and cardiac arrest requiring
defibrillation These episodes occurred in the intensive
care unit despite discontinuation of all QT prolonging
medications and a normal electrolyte panel Each episode
responded to defibrillation with return to normal sinus
rhythm Interventional cardiology was consulted for fur-ther evaluation and treatment and she was transferred
to the Cardiac Critical Care Unit After failure of medi-cal management and persistent prolonged QT syndrome, the diagnosis of congenital long QT syndrome was made This was acutely exacerbated by secretory diarrhea, elec-trolyte abnormalities, and QT prolonging medications
An implantable cardioverter defibrillator was placed on day 8 of her hospital stay and she was discharged home
on hospital day 10
Discussion & Conclusions
This case describes a rare presentation after a common outpatient procedure and a common postoperative com-plaint The case highlights the substantial electrolyte derangements that may be seen with persistent secretory diarrhea It also highlights the importance of prompt rec-ognition of long QT syndrome as if unrecognized, may result in sudden cardiac death Regarding the incidence
of the black box warning on the previously often used antiemetic, Droperidol Only 3 cases of TdP were discov-ered in over 200,000 surgical cases over a 6-year period While congenital LQTS is estimated to have a prevalence
of 1:3000–7000, the presentation of TdP in the periopera-tive setting is exceedingly rare Anesthesia providers fre-quently administer medications known to be associated
Fig 2 Torsades de Pointes in the PACU
Trang 4with QT prolongation (Fig. 4A) [2] Most sources agree
the QTc interval is considered to be prolonged if > 450 ms
to recognize the risk factors for QT prolongation and
as possible to avoid potential negative outcomes
The relevant medical literature includes several case reports of QT interval prolongation either acquired or congenital, descriptions of the pathophysiology underly-ing the condition, and monitorunderly-ing and treatment guide-lines for clinicians Mouyis et al [6] describes a case of an 81-year-old female with a 3-year history of noninfective
Fig 3 EKG in CCU capturing recurrent Torsades de Pointes
Fig 4 A Perioperative Medications with Known Risk for QT prolongation B Risk factors for prolonged QTc and TdP
Trang 5Page 5 of 6
Schaar et al BMC Anesthesiology (2021) 21:302
diarrhea and recurrent syncopal events over the
preced-ing 3 months She was admitted to the cardiology service
where telemetry and holter analysis confirmed multiple
episodes of Torsade de Pointes She was eventually
dis-charged after ICD placement The authors concluded
that chronic diarrhea can result in life threatening
poly-morphic VT due to hypokalemia and QTc prolongation
and that ICD placement should be considered in these
drug induced TdP including hypokalemia, female sex,
drug-drug interactions, advancing age, genetic
predis-position, hypomagnesemia, heart failure, bradycardia,
describes a case of TdP in a child undergoing an
outpa-tient procedure (myringotomy) The paoutpa-tient had known
congenital LQTS with an AICD in place The AICD failed
perioperatively resulting in TdP requiring external
occurring in self-limiting bursts, causing dizziness and
syncope, yet may occasionally progress to ventricular
fibrillation and sudden death Furthermore, management
of TdP includes removal or correction of precipitants,
including discontinuation of culprit drugs and
institu-tion of cardiac monitoring Electrolyte abnormalities and
hypoxia should be corrected with potassium
concentra-tions maintained in the high normal range Immediate
treatment is by intravenous administration of
magne-sium sulfate, terminating prolonged episodes using
elec-trical cardioversion, and expert consultation There are
numerous forms of congenital long QT syndrome and
the classification/ pathophysiology of these conditions is
available to review in other resources
The number of known medications with QT
prolong-ing potential is well over 200 (AZCERT, Inc.) A
refer-ence to many, yet not all, commonly used perioperative
medications with a known risk (KR) of TdP is available in
sev-eral risk factors predisposing her to this episode of TdP
including marked electrolyte derangements, the
admin-istration of more than one QT prolonging medication,
female gender, and her undiagnosed congenital
conduc-tion abnormalities It is also imperative to recognize that
her history of presumed “paroxysmal SVT” should have
prompted further questioning and investigation It is
most likely that her history of previous syncopal episodes
were episodes of TdP that she miraculously survived
without intervention The history of syncope attributed
to an arrhythmia (albeit undiagnosed) may represent a
life-threatening condition and appropriate evaluation
should be performed to avoid potential catastrophic
outcomes
The primary lesson of this case report includes having a high index of suspicion for electrolyte derangements after chronic diarrhea complicated by bowel preparation and minimal oral intake in the preceding days Additionally,
it highlights the importance maintaining a broad differ-ential diagnosis and considering uncommon conditions when evaluating patients with seemingly common pres-entations such as post-operative nausea and vomiting
In conclusion, we believe it would be reasonable to con-sider pre-operative laboratory and/or electrocardiogram
in patients with known or suspected cardiac conduc-tion abnormalities and those with a history of prolonged secretory diarrhea given the potential for marked electro-lyte derangements
Patient perspective
N/A
Informed consent
Obtained; available on file
Abbreviations
TdP: Torsades de Pointes; PSVT: Paroxysmal Supraventricular Tachycardia; PACU : Post anesthesia care unit; EKG: Electrocardiogram; mg: Milligrams; IV: Intravenous.
Acknowledgements
None.
Authors’ contributions
AS is the primary author and corresponding author of this case report This author was directly involved in this patient’s care, obtained the patient’s writ-ten consent, drafted the report, and submitted the report ML helped with the clinical decision making during the case as well as with editing of the drafted report MP also helped with the editing of the drafted report All authors have read and approved the manuscript.
Funding
None.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Written consent to publish this information was obtained from the patient discussed in the case report.
Competing interests
None.
Received: 14 July 2021 Accepted: 28 September 2021
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